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Dedicated to increasing awareness about
systemic lupus erythematosus (SLE), disease activity and related organ damage

Mainstay Treatments and Balancing Risks and Benefits

Mainstay treatments in SLE can include antimalarials, nonsteroidal anti-inflammatory drugs (NSAIDs), and low doses of corticosteroids for less severe disease. These modalities are helpful in treatment of mild symptoms such as arthralgias and musculoskeletal cutaneous manifestations.1

For more severe disease, corticosteroids and cytotoxic and immunosuppressive agents are used in patients with significant organ involvement and severe cutaneous manifestations.1

sle treatment options sle treatment options sle treatment options

"All drugs have potential side effects, so the balance of risk versus benefit is always at the forefront of a [SLE] treatment regimen." — Levy, DM, et al2

Managing patients with SLE can be a balancing act, weighing risk versus benefit in the available treatments for SLE.2 Consider the following treatment-related complications that may occur in patients with SLE:

  • Opportunistic infections and certain malignancies can develop, most often in patients receiving chronic immunosuppressive therapy3
  • Chronic corticosteroid use is associated with cataracts, diabetes mellitus, atherosclerotic heart disease, osteoporosis and osteonecrosis, and fluid retention4
  • Long-term use of NSAIDs is associated with GI bleeding and kidney damage4

Learn more about managing this complex, challenging condition.

In the treatment of SLE, the mechanism of action of antimalarials is not fully understood; their anti-inflammatory and immunosuppressive properties may help explain their effectiveness.1

Antimalarials have been associated with reduced disease activity, reduced risk of flares and organ damage, and reduced mortality.5-9

Improved ophthalmology screening tools and new knowledge on prevalence of toxicity can help clinicians minimize vision loss.10

When monitoring for antimalarial toxicity in patients with SLE, consider the following:

  • Most common side effects: gastrointestinal upset, dermatologic reactions, headache, and lightheadedness1
  • Rare but serious side effects include psychosis, convulsions, toxic neuropathy, skeletal myopathy, cardiac myopathy, and ophthalmologic toxicity, including vision loss1
  • American College of Rheumatology recommends a baseline examination (funduscopy and visual field) prior to initiating antimalarial treatment1,11
    • Follow up ophthalmologic assessments every 6-12 months1,11

Immunosuppressant agents are typically reserved for more severe disease, as well as for patients who have active disease despite antimalarials and/or glucocorticoids.1 They can be used in induction and maintenance of remission and reduction of flares or relapses.8 Immunosuppressants can also be given in combination with glucocorticoids to control flares, or to lower the dose of each medication; or to reduce incidence of adverse events.11

Some immunosuppressant agents may be used to treat neuropsychiatric symptoms and severe cutaneous manifestations.1

When monitoring for immunosuppressant toxicity in patients with SLE, consider the following:

  • Potential adverse events include (varies with specific medications in this class):
    • Myelosuppression11
    • Hepatotoxicity11
    • Renal dysfunction11
    • Infertility11
    • Increased risk of infection and/or cancer11
  • Common monitoring parameters:
    • Baseline and routine CBC, platelet count, SCr, LFTs, and urinalysis (depending on individual drug)11

Owing to their potent anti-inflammatory effects, glucocorticoids are used to treat a wide number of rheumatic diseases, including SLE and its manifestations:

  • Low-to-moderate doses used for mucocutaneous and vasculitic skin lesions (with no organ involvement)13
  • Useful for moderate-to-severe polyarthritis13
  • High doses used for major organ involvement13

When monitoring for glucocorticoid toxicity in patients with SLE, consider the following:

  • Adverse effects of glucocorticoids is time- and dose-dependent14
Adverse effect Time-dependent Dose-dependent
Osteoporosis Yes (early) Yes (maximum 6
months)
Hyperglycemia Yes (early) Yes
Cushing
Syndrome
Yes (at least 1
month)
Yes
Cardiovascular
disease
Yes Yes
Increased risk of
infections
Yes Yes
Dermatologic Yes Yes
Glaucoma Yes Yes
Cataracts Yes (delayed) Yes
Psychological and
behavioral
Yes (early) Yes

DID YOU KNOW?

It costs an estimated additional $784 per year per patient on steroids to manage adverse events associated with steroid use compared with non-users (n=2717).12,*

*

A retrospective cohort analysis conducted in the US Truven Health MarketScan® Commercial Claims and Encounters Database, n=762

PATIENT CASE STUDY: ALICIA

patient alicia

Alicia has been treated with glucocorticoids but still experiences frequent mobility and fatigue issues, as well as arthritis flares.

This is a hypothetical patient.

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LEARN MORE ABOUT SLE

This slide deck discusses the path to diagnosis of SLE, pathogenesis of the disease, impact on patients, and how to best support patients.

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What Next?

Prevention of flares (especially severe flares) is a realistic target in SLE and should be a therapeutic goal.15

Learn more now

References:
1. Bernknopf A, Bailey T, Rowley K. A review of systemic lupus erythematosus and current treatment options. Formulary Journal. 2011;46(5):178-194. http://formularyjournal.modernmedicine.com/formulary-journal/news/clinical/clinical-pharmacology/review-systemic-lupus-erythematosus-and-curren?page=full. Accessed February 14, 2017. 2. Levy DM, Kamphuis S. Systemic lupus erythematosus in children and adolescents. Pediatr Clin North Am. 2012;59(2): 345–364. http://dx.doi.org/10.1016/j.pcl.2012.03.007. Accessed February 14, 2017. 3. Bartels CM. Systemic Lupus Erythematosus (SLE) Treatment & Management. Medscape. http://emedicine.medscape.com/article/332244-treatment. Updated September 25, 2015. Accessed February 14, 2017. 4. American College of Rheumatology Ad Hoc Committee on Systemic Lupus Erythematosus Guidelines. Guidelines for referral and management of systemic lupus erythematosus in adults. Arthritis Rheum. 1999;42(9):1785-1796. http://www.ncbi.nlm.nih.gov/pubmed/10513791. Accessed February 14, 2017. 5. Willis R, Seif A, McGwin G, et al. Effect of hydroxychloroquine treatment on pro-inflammatory cytokines and disease activity in SLE patients: data from LUMINA (LXXV), a multiethnic US cohort. Lupus 2012;21:830-835. http://dx.doi.org/10.1177/0961203312437270. Accessed February 14, 2017. 6. The Canadian Hydroxychloroquine Study Group. A randomized study of the effect of withdrawing hydroxychloroquine sulfate in systemic lupus erythematosus. N Engl J Med. 1991;324:150-154. http://dx.doi.org/10.1056/NEJM199101173240303. Accessed February 14, 2017. 7. Fessler B, Alarcon G, McGwin G, et al. Systemic lupus erythematosus in three ethnic groups. Arthritis Rheum. 2005;52:1473-1480. http://dx.doi.org/10.1002/art.21039. Accessed February 14, 2017. 8. Akhavan PS, Su J, Lou W, et al. The early protective effect of hydroxychloroquine on the risk of cumulative damage in patients with systemic lupus erythematosus. J Rheumatol. 2013;40(6):831-841. http://dx.doi.org/10.3899/jrheum.120572. Accessed February 14, 2017. 9. Alarcon G, McGwin G, Bertoli A, et al. Effect of hydroxychloroquine on the survival of patients with systemic lupus erythematosus: data from LUMINA, a multiethnic US cohort (LUMINA L). Ann Rheum Dis. 2007;66:1168-1172. http://dx.doi.org/10.1136/ard.2006.068676. Accessed February 14, 2017. 10. Marmor MF, Kellner U, Lai TY, et al. Revised recommendations on screening for chloroquine and hydroxychloroquine retinopathy. Ophthalmology. 2011;118:415-422. http://dx.doi.org/10.1016/j.ophtha.2010.11.017. Accessed February 14, 2017. 11. Maidhof W, Hilas O. Lupus: an overview of the disease and management options. Pharm Thera. 2012;37(4):240-249. http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3351863/pdf/ptj3704240.pdf. Accessed February 14, 2017. 12. Shah M, Chaudhari S, McLaughlin TP, et al. Cumulative burden of oral corticosteroid adverse effects and the economic implications of corticosteroid use in patients with systemic lupus erythematosus. Clin Ther. 2013; 35(4): 486-497. http://dx.doi.org/10.1016/j.clinthera.2013.03.001. Accessed February 14, 2017. 13. Touma Z, Urowitz MH. Systemic glucocorticoids. In: Tsokos G, ed. Systemic Lupus Erythematosus. Basic, Applied and Clinical Aspects. London, UK: Academic Press;2016:521-529. 14. Ruiz-Irastorra G, Danza A, Khamashta M. Glucocorticoid use and abuse in SLE. Rheumatology. 2012;51:1145-1153. http://dx.doi.org/10.1093/rheumatology/ker410. Accessed February 14, 2017. 15. van Vollenhoven RF, Mosca M, Bertsias G, et al. Treat-to-target in systemic lupus erythematosus: recommendations from an international task force. Ann Rheum Dis. 2014;73(6):958-967. http://dx.doi.org/10.1136/annrheumdis-2013-205139. Accessed February 14, 2017.